GW1--00945_Well Construction - GW1_20240208

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Frankie L. Oliver 14.WATER ZONES , ,
FROM TO DESCRIPTION
Well Contractor Name 173 ft 358 ft
3002-A 392 ft' 405 ft. 1
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased',wells)OR LINER(if applicable) '
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
in' SDR21
Company Name ,,16.INNER.CASING OR TUBING
gER(geothermal closed-loon)
lo d-loo ) MATERIAL
0 ft. 50 61/4;
FROM
NESS
2.Well Construction Permit#: 22-325
List all applicable roll construction permits(i.e.111C,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: `17.SCREEN
FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL
(Agricultural EIMunicipal1Public ft. rt. in.
DGeothetmal(Heating/Cooling Supply) r jiResidential Water Supply(single) ft ft. in.
0Industrial/Commercial QIResidential Water Supply(shared) 'lti:GROUT
Illrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 50 ft' Bentonite Pump (11)501b Bags
Monitoring InRecovety ft. ft.
Injection Well:
ft. ft.
ElAquifer Recharge IDGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable) '
0Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test tStomrwater Drainage rt. ft
Experimental Technology OSubsidence Control it. [t
Geothermal(Closed Loop) OTracer 20.DRILLING LOG.(attach additional sheets if necessary) "
FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
f Geothermal(Heating/Cooling Return) nOther(explain under#2I Remarks)
0 ft- 14 ft. Brown Clay
4.Date Well(s)Completed: 12-20-23 Well ID# 14 ft' 625 ft Blue Slate
5a.Well Location: ft ft
Domino Salto ft ft .F-T -...',1, F. h
7M
g ft ft. b{. '�n..�t ^r
Facility/Owner Name Facility ID#(if applicable)
6022 Pageland Hwy Monroe 28112 ft. ft FEB 0 S 2024
Physical Address,City,and Zip it ft. iflferieft 41P(1 )rn,..,., ..-e 1_ .
Union 03-180-005 21.REMARKS' '. - , • ri,_,-,3 .,'
County Parcel Identification No.(PIN) '
*50'casing and full length grout as per permit*
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ,
34.86.136 N 80.44.396 •
1-15-24
6.Is(are)the well(s)E1Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form, 1 hereby cert(fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: )jYes or EINo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this,fonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 625 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2Q100) construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1/2 Method of test: Air 24c.For Water Sunray & Injection Wells: In addition to sending the form to
• the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: 70% HTH _ Amount: 36oz completion of well construction to,the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016